After six years of steady decreases in new HIV cases in San
Francisco, the end of that trend in 2012 is causing concern among local health
officials.

The city registered 413 new HIV diagnoses in 2012, a slight
increase from the 406 reported in 2011.

While that may not appear significant, it is a troubling
sign that the city's HIV prevention efforts may have reached a plateau. And it
could prove problematic for reaching the city's goal of reducing new HIV
infections among gay and bisexual men, as well as transgender persons, by 50
percent in 2015.

"We cannot say new infections are going up," said
Tracey Packer, the health department's director of community
health equity and promotion who oversees the city's HIV prevention efforts.
"We can say we think the trend is going down and it is not."

The city will have a clearer picture of where the trend in
HIV cases is headed later this year when the 2013 data is released.

Based on the most recent HIV/AIDS surveillance report,
released in June 2013, there is some evidence to suggest that new HIV diagnoses
either remained stable or decreased last year.

The quarterly report indicated that during the first half of
the year the city recorded 159 new HIV diagnoses. That was down from the 176
new cases recorded in the June 2012 quarterly surveillance report.

"I think it is a really good time to look closely at
all the data we have in combination. I don't think we have enough information
yet to say it is not decreasing significantly," said Packer.

Nor do health officials know "what is causing the
potential uptick," she added.

Presenting the most recent year-to-date figures to the
city's HIV Prevention Planning Council last week, Henry Fisher Raymond, an
epidemiologist with the Department of Public Health's Center for Public Health
Research Branch, said the number of new HIV diagnoses in 2012 should have been
below 400 for the data to indicate ongoing declines in HIV cases.

Instead, the uptick in cases "is really
disconcerting," Raymond told the council, which prioritizes what HIV
prevention strategies the city should be funding.

Raymond also pointed to an increase seen in the number of
HIV cases among men who have sex with men between 2010 and 2011 as another
troubling indicator. The city recorded 279 such cases in 2010 and 307 in 2011.
In 2004 the number was 630 cases among gay and bisexual men.

"The overall trend from 2004 to 2011 is promisingly
headed down. The question is whether the slight uptick from 2010 to 2011 is due
to more infections or a result of more work being done to identify HIV cases
through testing initiatives," Raymond told the Bay Area Reporter
in an emailed response to questions following his
presentation.

During the HPPC meeting Raymond was quick to emphasize that
it remains unclear if "things are on the upswing again" or if the
increased efforts to test people at risk of contracting HIV are behind the
numbers.

"We are paying very much attention to if this is a
welcome artifact of increased testing," he said.

Packer told the B.A.R. that
HIV testing in the city has significantly increased since the implementation of
what is known as a "test and treat" policy. The city has prioritized
testing as many people at risk for HIV as possible and getting those who test
positive into treatment soon after their diagnosis.

In 2010 there were 17,000 HIV tests administered by
city-funded clinics; in 2013 that number had grown to 27,000 HIV tests, said
Packer.

That has resulted in a decline in the number of people in
San Francisco estimated not to know they are HIV-positive. In 2008 it was
thought that 15 percent of people didn't know they were positive, said Packer,
and in 2013 that estimate was down to 6.4 percent.

Nonetheless, the HPPC and health officials are re-examining
their efforts to prevent the spread of HIV in the city.

"This is an opportunity to think about what has gone
well and what needs to be rethought," Packer said.

One focus for health officials is eradicating HIV
transmission among injection drug users. The HPPC set a goal of eliminating new
HIV infections among IDUs by 2015.

The number of IDU HIV cases continues to decline, but it is
unclear if the city will meet its goal. In 2011 there were 69 cases, dropping
to 51 cases in 2012, according to the data Raymond presented last week.

"We are headed in the right direction but maybe not
fast enough," he said.

Among the troubling signs in the data on IDUs, the
proportion who do not know their HIV status "is quite high," said
Raymond.

The number of users in 2012 who reported getting tested
every six months was below 40 percent, down from a high of 60.7 percent in
2005. Just 52.2 percent of IDUs reported in 2012 having an HIV test within the
last year, down from 74.5 percent in 2005.

"The big question is why are fewer IDUs saying they got
tested in the last six or twelve months? I think we need to take a closer look
there," said Raymond.

The use of clean needles has dropped slightly, going from
62.6 percent of IDUs saying they "always" did in 2005 to 60.4 percent
in 2012. Over the same timeframe, 62.2 percent of IDUs reported engaging in
unprotected intercourse, suggesting that sexual behavior "may be
contributing" to new HIV infections, reported Raymond.

HPPC member Laura Thomas, the Drug Policy Alliance's deputy
state director for California, renewed calls for the city to establish safe
injection sites for IDUs as one way to help educate them about knowing their
HIV status and providing easy access to clean needles.

"We've got to be doing more to make a bigger
dent," said Thomas.

HPPC co-chair Jose Luis Guzman, the HIV
testing services coordinator at Magnet, the gay men's health center in the
Castro, agreed that the council needs to renew its efforts to reach the goal of
bringing the number of new HIV cases among IDUs to zero next year.

"Let's do what we did with perinatal infections with
IDUs," said Guzman, referring to the city's elimination of HIV
transmission between pregnant women and their newborn infants.